Strategies and Devices to Minimize Stroke in Adult Cardiac Surgery

Prophylactic Left Atrial Appendage Ligation During Coronary Artery Bypass Graft Surgery Allows Safe Avoidance of Anticoagulation Regardless of Postoperative Atrial Fibrillation

Background New-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery. POAF increases the risk of thromboembolism and stroke, as well as morbidity and mortality more generally. Despite evidence from the landmark PROTECT-AF and PREVAIL trials, left atrial appendage ligation (LAAL) is not routinely performed for thromboembolism prophylaxis in POAF, and anticoagulation remains the standard of care along with dual antiplatelet therapy. This study evaluated the efficacy of concomitant LAAL in eliminating the need for postoperative anticoagulation, regardless of POAF development, in patients undergoing coronary artery bypass grafting (CABG). Methods Between 2019 and 2021, 130 patients were selected to undergo concomitant LAAL while undergoing CABG surgery. Patients were then monitored for the incidence of new-onset POAF, and anticoagulation was strictly avoided for this indication. Demographic and outcome data were collected, with endpoints including transient ischemic attack (TIA) or stroke, death, and readmission within one year, as well as the length of hospital and intensive care unit (ICU) admissions. Results POAF occurred in 37 patients (28.5%), consistent with previous reports. However, none of the POAF patients experienced TIA or stroke during the one-year follow-up period, compared to 2 (2.15%) in the non-POAF group, a typical rate of postoperative stroke in such a patient population. No significant differences were observed between POAF and non-POAF cohorts in one-year stroke, all-cause mortality, readmission rates, or total hospital stay. Interestingly, the POAF cohort had a significantly longer mean ICU stay (4.24 vs 3.37 days, p = 0.0219), possibly due to the time required for arrhythmia control before discharge. The study population had a high mean CHA2DS2-VASc score (2.81), indicating an increased risk of thromboembolism, and a high mean HAS-BLED score, suggesting an elevated bleeding risk with anticoagulation. Conclusions LAAL appears to be an effective adjunct to CABG for thromboembolism prophylaxis in POAF. Formal anticoagulation was avoided in this study, with no significant differences in adverse events between POAF and non-POAF groups, suggesting that LAAL may be a suitable alternative to anticoagulation, especially in high-risk patients (e.g., those with elevated CHA2DS2-VASc or HAS-BLED scores). The safety and efficacy of this approach should be corroborated by larger randomized studies, such as the ongoing LeAAPS trial. LAAL during CABG may help reduce the risk of bleeding complications associated with anticoagulation while maintaining protection against thromboembolic events in patients who develop POAF.

Atrial Septal Defect Repair in Adolescent and Adult Patients, a Cross Sectional Study at Jordan University Hospital, a Tertiary Hospital in a Developing Country

Objective

We aim to report our heart team's experience in repair of Secundum atrial septal defect (ASD) in adolescent and adult patients at Jordan University Hospital (JUH).

Methodology

A retrospective observational study of 44 patients who underwent secundum ASD closure by transcatheter closure (TCC) or Minimally Invasive Cardiac Surgery (MICS) at JUH. Patients who were treated at an age of 14 years or older regardless of the age of diagnosis were included. SPSS and Microsoft Excel were used to analyze the data.

Results

A total of 44 patients with secundum ASD were treated during the period of (January 2015 and December 2019). The mean age was 34.1 (±14.3) years. Thirty-four patients underwent TCC, 9 underwent surgical closure and one had a hybrid procedure. We had no mortality and 2 minor morbidities. After a mean follow-up period of 13.2-/+13.6 months, most patients experienced improved symptoms, and there was a significant reduction of right ventricular dimension from 33.1 (±8.74) to 24 (±4.67) mm (p=0.0001).

Conclusion

ASD closure whether TCC or MICS is a safe procedure with very low morbidity. A heart team approach is a necessity in the era of advances in both MICS surgery and TCC approach. A heart team provides the patients with a variety of safe and cosmetic solutions that allow the patients to have a fast management and recovery phase in rapid time through providing the merits and avoiding the complications of each modality, the team allows low volume centers in developing countries to achieve an excellent outcome.

Effect of perioperative acetaminophen on body temperature after cardiovascular surgery with cardiopulmonary bypass: A single-center retrospective study

Context:

Postoperative hyperthermia, which may lead to cognitive decline, is a common complication of cardiovascular surgery with cardiopulmonary bypass (CPB).

Aims:

The aim of this study was to examine the effectiveness of perioperative intravenous acetaminophen on body temperature in adult patients after cardiovascular surgery with CPB.

Settings and Design:

This was a single-center retrospective study focusing on adult patients who underwent elective cardiovascular surgery with CPB at a university hospital in Japan.

Subjects and Methods:

Patients were divided into two groups based on whether they received acetaminophen perioperatively. In the acetaminophen group, 15 mg/kg intravenous acetaminophen solution was infused at 30 min after discontinuation of CPB and every 6 h after intensive care unit (ICU) admission.

Statistical Analysis Used:

The primary outcome was the maximum axillary temperature within 12 h after ICU admission. The effects of acetaminophen on postoperative body temperature were estimated by the standardization and inverse probability weighting using propensity scores.

Results:

A total of 201 patients were included in the final analysis (acetaminophen group, n = 101; non-acetaminophen group, n = 100). The maximum axillary temperature within 12 h after ICU admission was 37.20 ± 0.54°C in the acetaminophen group and 37.78 ± 0.59°C in the non-acetaminophen group. Acetaminophen lowered the standardized mean of primary endpoint (−0.54°C, 95% confidence interval, −0.69 to −0.38) compared to non-acetaminophen.

Conclusions:

Perioperative intravenous acetaminophen inhibited body temperature elevation after cardiovascular surgery with CPB, compared with the non-acetaminophen group.

Consequence of Ischemic Stroke after Coronary Surgery with Cardiopulmonary Bypass According to Stroke Subtypes

Introduction

The aim of this study was to determine the outcomes of patients developing ischemic stroke after coronary artery bypass grafting (CABG).

Methods

From March 2012 to January 2017, 5380 consecutive patients undergoing elective coronary surgery were analyzed. Ninety-five patients who developed ischemic strokes after on-pump coronary surgery were included in the study, retrospectively. The cohort was divided into four subgroups [total anterior circulation infarction (TACI), partial anterior circulation infarction (PACI), posterior circulation infarction (POCI), and lacunar infarction (LACI)] according to the Oxfordshire Community Stroke Project (OCSP) classification. The primary endpoints were in-hospital mortality, total mortality, and survival analysis over an average of 30 months of follow-up. The secondary endpoints were the extent of disability and dependency according to modified Rankin Scale (mRS).

Results

The incidence of stroke was 1.76% (n=95). The median age was 62.03±10.06 years and 68 (71.6%) patients were male. The groups were as follows: TACI (n=17, 17.9%), PACI (n=47, 49.5%), POCI (n=20, 21.1%), and LACI (n=11, 11.6%). Twenty-eight (29.5%) patients died in hospital and 34 (35.8%) deaths occurred. The overall mortality rate of the TACI group was significantly higher than that of the LACI group (64.7% vs. 27.3%, P=0.041). The mean mRS score of the TACI group was significantly higher than that of the other groups (P=0.003).

Conclusion

Patients in the TACI group had higher in-hospital and cumulative mortality rates and higher mRS scores. We believe that use of the OCSP classification and the mRS may render it possible to predict the outcomes of stroke after coronary surgery.

Impact of Modified Transesophageal Echocardiography on Mortality and Stroke after Cardiac Surgery: A Large Cohort Study

The aim of this study was to investigate the impact of perioperative screening with modified transesophageal echocardiography (A-View method). We compared, in consecutive patients who underwent cardiac surgery between 2006 and 2014, 30-day mortality and in-hospital stroke incidence, operated either with perioperative modified TEE screening (intervention group) or only with conventional TEE screening (control group). Of the 8,605 study patients, modified TEE was applied in 1,391 patients (16.2%). Patients in the intervention group were on average older (71 versus 68 years, p < 0.001) and more often females (31.0% versus 28.0%, p < 0.001) and had a higher predicted mortality (EuroSCORE I: 5.9% versus 4.0%, p < 0.001). The observed 30-day mortality was 2.2% and 2.5% in both groups, respectively, with multivariable and propensity-score adjusted relative risks (RRs) of 0.70 (95% CI: 0.50–1.00, p = 0.05) and 0.67 (95% CI: 0.45–0.98, p = 0.04). In-hospital stroke was 2.9% and 2.1% in both groups, respectively, with adjusted RRs of 1.03 (95% CI: 0.73–1.45) and 1.01 (95% CI: 0.71–1.43). In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening.